croaker260

Actually , bioavailability of rectal drugs (as a generalization ) tends to be about 0.8 where IV bioavailability approaches 1.0.. as a general rule. See CHBARES comments on 0 order elimination above.

Not the one I was looking for, but I ended up using it in my project anyway. Thanks!

The other side of this is that unfortunately, even in the US, DC FEMS takes the cake for dysfunctional EMS systems and anything goes. Detroit Fire/EMSby coparison has a huge level of dysfunction, but most of it is beyond the control of the street level provider. DC FEMS has no excuse.

OK, those who know me know I have an interest in street drugs and lecture a lot on them as well as try to keep abreast, etc. So its not often that I get stumped. In a HIPAA SAFE, HYPOTHETICAL (wink wink) galaxy far far away.... EMS unit was requested to assist local LEO with a patient in opioid withdrawal The patient in question was being detained for a period in time while an investigation is going on. As this period of time progressed, the patient became dope sick (withdrawal) to the point LE were somewhat concerned and wanted to have the patient assessed. The patient in question uses IV opioids 8-10 times per 24 hour period, typically crushing and desolving prescription opioids. he has been following this pattern of use in excess of 2 years. What the patient takes largely depends on what he can get, but typically Oxy or Dilaudid 8 mg. The patient will combine with meth as the mood strikes, and also will use Heroin as needed if he cant get his normal fix. So, not that abnormal. Unfortunate, but not abnormal. Here's where it takes a turn into left field. The patient also reports that in addition to IV opioid use, the patient routinely uses Vodka and/or everclear instead of water to disolve the pill fragments in. he reports that he has also been doing this essentially uninturupted for the previous two years. The patient reports its a more complete desolution, as well as a more intense effect on injection. My questions/discussion points are: 1- Knowing that this route would bypass 1st pass metabolism, what is the thoughts on tolorance, and/or toxicity? 2- Given #1 above, and the reported duration of use (2 plus years) what is the risk for alcohol withdrawal and DT over the next 12-48 hours? 3- what is the prevelance of this practice? I've posted this to the Docs and other knowledgeable people and recived the same puzzeled looks.

Many thanks guys, but no, none of those. The Mort study I already have as a foundation reference in my proposal, but I need this specific artcile for a specific point.

I am writing a proposal, and am trying to recall a study I read many years ago. It was a study that reported that # of ETT attempts, independant of other difficult airway factors, also increased the difficulty of the ETT attmept. In other words, everytime you placed the blade in the mouth of the patient the chance of failure increased. IIRC the chance increased to 25% by the third attempt. It was from long enough ago that I didnt scan and PDF it. For the life of me I cant find that study now. I am 75% sure it came from the ASA or from the Annals of Emergency medicine, but I could be wrong. My google-fu and pubmed-fu and kung fu are all failing me today. Ive been looking for two days. Anyone recall that study and have the citation? or betteryet the actual PDF? Many Thanks.

I was 90% sure that PR used the NREMT also, being a US terratory

This is an excellant overview of the science and theory. http://www.epmonthly.com/archives/features/no-desat-/ I personally have had it save my ass on at least on occasion and prevent a difficulty airway . It was a adult male in status SZ for about 60-90 minutes prior to 911 call, how had been trached int he past. His family finally called us after they shoved a plastic toddler spoon in his mouth and caused further trauma. Anyway, multiple Bezo's at max doses had failed to break the SZ, and the patients SPO2 was dropping (was abotu 65-70% on NRB) . He was also hyperthermic from fever and/or muscle activity. Airway positioning and suctioning was poor due to trismus. We were literally facing a crash airway, but with his prior trachs and anatomy, RSI/MAI was the last thing I wanted to do. Remembering this tool in the tool box, I dropped the NC at 15 LPM as we prepared for the inevitable RSI. Immediatley (under 2 minutes) his SPO2 came up to 97-99%. Being very happy with this, we continued transport, and he was subsequently intubated after three attempts with a glide-a-scope by the anesthesiologist (we had called ahead and they were waiting). Looking over the docs shoulder during the attempt, I was really glad we didnt have to try in the field.

We also use the CAREVENT ATV+CPAP at my service, and at my PT gig. At my main service we use a different CPAP, but otherwise both are very pleased with them. Ive used them on a variety of adult and large ped patients. I have not used them on the very small.

For those of you that have these devices, or have trialed them: What make/model are you guys using in your individual services, what guidelines do you have for their use, and any lessons learned from your experiance?

I think what ERDoc is trying to say is HOW did the "Paramedic" "clear" ( a misuse fo the term) the c-spine. What assessments did he perform. What he is wondering is if he did it "correctly". Saying Selective Spinal Immobilization (AKA "Clearing the C-Spine" ) protocols dont work, if they were misused in the first place, is not an accurate, or helpful, statement.

We currently use Ketamine in my area, and I do not recall seeing anything like trismus, other than the brief fasciculations you occasionally see with succs. That said I routinely use a little Midazolam pre-intubation in my "cocktail" as well (2.5-5 mg). I started using this back when we used etomidate instead at the recomendation of a local doc, as we were seeing myoclonic fasciculation /trismus with Etomidate. Since I aded a little versed, havent seen it since. So that would be my recomendation. I know some medics think that using ketamine removes the need of Midazolam altogether, but I think they work well together. With a paralytic too , of course.

Hehe I left TN in 1998, arrived at ACP for academy "December 7th, a day wich will live in infamy forever"... So yeah, its been a while. I try not to think about it too much. And its a good thing you put WE in that statement about old and gray...

http://www.hulu.com/watch/539028 "E-meth"

http://www.adaweb.net/paramedics/AboutUs/StandingWrittenOrders.aspx The specific protocol that pertains is here: http://www.adaweb.net/LinkClick.aspx?fileticket=_jCsKmENMhE%3d&tabid=4660 The protocol as written does not sufficently emphasise the true paradigm, shift. As a single sentance states, the KED and LSB are for extrication, not for immobilization. As anywhere, there are always some things to complain about...it is EMS after all...but yes, its a great place to practice. I've been here 15 years and counting.